The Syncope Unit: How To Better Organise It? The European Experience

Experience

M. B

Current Syncope Management (Diagnosis and Treatment)

Syncope is a common symptom in the community and in emergency medi- cine. For example, in the UK, syncope and collapse (ICD code 10) are the sixth most common reason for the immediate admission of adults > 65 years to medical hospitals. Given that half of all emergency admissions involve persons over age 65, this constitutes a large volume of activity. The average length of stay for these admissions is 5–17 days, which reflects the diversity of syncope management strategies and the availability of certain tests. Hospital admission alone accounted for 74% of the cost of investigating syncope [1].

Currently, the strategies for assessing syncope vary widely among physi- cians as well as among hospitals and clinics. More often than not, the evalua- tion and treatment of syncope are haphazard and unstratified. The result is a wide variation in the diagnostic tests applied, the proportion and types of attributable diagnoses, and the proportion of syncope patients in whom the cause remains unexplained [1–5]. For example, in a prospective registry [3]

enrolling patients referred to the emergency department from 28 general hospitals in Italy, carotid sinus massage was performed in 0–58% and head- up tilt tests in 0–50% of syncopal patients. Consequently the final diagnosis for neurally mediated syncope ranged from 10% to 79%. These disparate pat- terns of assessment can explain why pacing rates for carotid sinus syndrome vary, even within countries, from 1% to 25% of implants, depending on whether carotid sinus hypersensitivity is systematically assessed in the

Centro Aritmologico, Dipartimento di Cardiologia, Ospedali del Tigullio, Lavagna

(Genua), Italy

investigation profile. Some authors have evaluated the impact of the intro- duction of in-hospital protocols [2, 5]. These studies showed that it is possi- ble to improve diagnostic rates and the use of appropriate investigations.

However, many inappropriate investigations and hospital admissions still occur. As a consequence, costs of investigations and costs per diagnosis have increased rather than decreased.

If the status quo for the evaluation of syncope remains unchanged, diag- nostic and treatment effectiveness is unlikely to improve substantially.

Furthermore, the implementation of the published syncope management guidelines will be diverse and incomplete. Thus, to maximise implementa- tion of the guidelines it is crucial that models of care for the assessment and management of syncope are implemented and that information about the models within each organisation is adequately communicated to all parties involved with syncope patients.

It is the view of the Task Force on Syncope of the European Society of Cardiology [6, 7] that a cohesive, structured care pathway delivered either within a single syncope facility or as part of a multifaceted service is the optimal approach to quality service delivery (Table 1). Furthermore, consid- erable improvements in diagnostic yield and cost effectiveness (i.e., cost per reliable diagnosis) can be achieved by focusing skills and by following well- defined up-to-date diagnostic guidelines.

Table 1. Recommendations of the European Society of Cardiology for the management of the patients with syncope

A cohesive, structured care pathway–delivered either within a single syncope facility or as part of a more multifaceted service–is recommended for the global assessment of patients with syncope

Experience and training in key components of cardiology, neurology, and emergency and geriatric medicine are pertinent

Core equipment for the facility include: surface ECG recording, phasic blood-pressure monitoring, tilt-table testing equipment, external and internal (implantable) ECG loop recorder systems, 24-h ambulatory blood pressure monitoring, 24-h ambulatory ECG, and autonomic function testing

Preferential access to other tests or therapy for syncope should be guaranteed and stan- dardised

The majority of syncope patients should be examined as out-patients or as day patients

Models Provided by Existing Syncope Management Units

The service model adopted by the Newcastle group is a multidisciplinary approach to referrals of patients with syncope or falls. All patients attend the same facility (with access to cardiovascular equipment, investigations, and trained staff) but are investigated by a geriatrician or cardiovascular physi- cian according to the dominant symptom cited in the referral correspon- dence, i.e. falls or syncope. Recently, this group showed that, over a period of 1 year, the hospital at which the day-case syncope evaluation unit was based had 6116 fewer bed–days for ICD code 10 categories, comprising syncope and collapse, compared to peer teaching hospitals in the UK. This reduction translated into a significant saving in emergency hospital costs (4 million Euros). The savings were attributed to a combination of factors: reduced re- admission rates, rapid access to day-case facilities for accident and emer- gency staff and community physicians, and reduced event rates because of effective targeted strategies for treating patients with syncope and falls [1].

The service model adopted in some Italian hospitals [8] consists of a functional unit managed by cardiologists w ithin the Department of Cardiology, with dedicated medical and support personnel. Patients admit- ted to the Syncope Unit have preferential access to all other facilities and investigations within the department, including admission to cardiology wards or the intensive care unit if indicated. When appropriate, patients are jointly managed with other specialists, e.g. neurologists. The patients are referred to the Syncope Unit (SU) from the emergency department or from in-patient or out-patient clinics, but SU personnel are not usually involved in the initial evaluation of the patient. This approach substantially improved the overall management of syncope compared to peer hospitals without such a facility [8] and reduced the number of unnecessary investigations.

Moreover, the appropriateness of indications and the diagnostic yield of tests increased; for example, in 66% of the patients, less than two tests were neces- sary for diagnosis [9].

Professional Skills Needed for the Syncope Evaluation Facility

It is probably not appropriate to be dogmatic regarding the training needs of

personnel responsible for a dedicated syncope facility. These skills will

depend on the pre-determined requirements of local professional bodies, the

level of screening evaluation provided prior to referral, and the nature of the

patient population typically encountered in a given setting. In general, expe-

rience and training in key components of cardiology, neurology, and emer-

gency and geriatric medicine are pertinent to the assessment and diagnosis

of syncope, in addition to access to other specialties, such as psychiatry, physiotherapy, occupational therapy, Ear Nose and Throat specialties, and clinical psychology.

Core medical and support personnel should be involved either full time or most of the time in management of the syncope unit, and should interact with all other stakeholders in the hospital and in the community.

Staff responsible for the clinical management of the facility should be conversant with recent guidelines on syncope management. A structured approach expedites clinical audit, patient information systems, service devel- opments, and continuous professional training.

Equipment

Core equipment for the syncope evaluation facility includes: surface ECG recording, phased blood-pressure monitoring, tilt-table testing equipment, external and internal (implantable) ECG loop recorder systems, 24-h ambu- latory blood-pressure monitoring, 24-h ambulatory ECG monitoring, and autonomic function testing. The facility should also have access to echocar- diography, intracardiac electrophysiological testing, stress testing, cardiac imaging, computed tomography and magnetic resonance imaging head scans, and electroencephalography.

Patients should have preferential access to hospitalisation and to any eventual therapy for syncope, namely pacemaker and defibrillator implanta- tion, catheter ablation of arrhythmias, etc.

Dedicated rooms for assessment and investigation are also required.

Setting

The majority of syncope patients can be investigated as out-patients or day patients. Indications for hospital admission are defined in the guidelines [6, 7].

The role of a local integrated syncope service is to set standards for the following in keeping with the objectives of the Guidelines on Syncope of the European Society of Cardiology and other appropriate guideline publica- tions:

1. The diagnostic criteria for causes of syncope

2. The preferred approach to the diagnostic work-up in subgroups of patients with syncope

3. Risk stratification of the patient with syncope

4. Treatment to prevent the recurrence of syncope

A major objective of the syncope facility is to reduce the number of hos- pitalisations by offering the patient a well-defined, quick, alternative evalua- tion pathway.

When establishing a newly structured service, current experience sug- gests that careful audit of the activity of the syncope unit activity and its performance will rapidly justify the initial resource allocation and requests for additional funding, fuel further service development, and provide a legit- imate magnet for increasing patient referrals.

Implementation in Clinical Practice of a Model of Structured Care Based on the Guidelines of the European Society of Cardiology

Recently, a prospective systematic evaluation of the strict adherence to the care guidelines of the European Society of Cardiology was undertaken in Italy [10]. The study consisted of consecutive patients referred for syncope to the emergency departments of 11 general hospitals. Trained core medical personnel both locally in each hospital and centrally who verified adherence to the diagnostic pathway and gave advices as needed for its correction was designated. In addition, decision-making guideline-based software was used to quantify the data. A diagnostic work-up consistent with the guidelines was completed in 465/541 patients (86%). A definite diagnosis was established in 98% (unexplained in 2%): neurally mediated syncope 66%, orthostatic hypotension 10%, primary arrhythmias 11%, structural cardiac or cardiopul- monary disease 5%, and non-syncopal attacks 6%. The initial evaluation (consisting of a history, physical examination, and standard electrocardio- gram) established the diagnosis in 50% of patients. Hospitalisation for the management of syncope was appropriate in 25% and was required for other reasons in a further 13% of patients. The median in-hospital stay was 5.5 days (interquartile range 3–9). Apart from the initial evaluation, a mean 1.9 ± 1.1 appropriate tests per patient were performed in 193 patients. The mean cost per patient was € 1216 (€ 2802 for those hospitalised and € 202 for those discharged from the emergency department. In conclusion, this study showed that a structured-care approach, developed according to cur- rent guidelines of the European Society of Cardiology, can be implemented in clinical practice.

References

1. Kenny RA, O’Shea D, Walker HF (2002) Impact of a dedicated syncope and falls

facility for older adults on emergency beds. Age Aging 31:272–275

2. Ammirati F, Colivicchi F, Santini M (2000) Diagnosing syncope in the clinical prac- tice. Implementation of a simplified diagnostic algorithm in a multicentre prospec- tive trial - the OESIL 2 study (Osservatorio Epidemiologico della Sincope nel Lazio). Eur Heart J 21:935–940

3. Disertori M, Brignole M, Menozzi C et al (2003) Management of syncope referred for emergency to general hospitals. Europace 5:283–291

4. Ammirati F, Colivicchi F, Minardi G et al (1999) Hospital management of syncope:

the OESIL study G Ital Cardiol 29:533–539

5. Farwell DJ, Sulke AN (2004) Does the use of a syncope diagnostic protocol improve the investigation and management of syncope? Heart 90:52–58

6. Brignole M, Alboni P, Benditt D et al (2004) Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J 25:2054–2072

7. Brignole M, Alboni P, Benditt D et al (2004) Guidelines on management (diagnosis and treatment) of syncope – Update 2004. Europace 6:467

8. Brignole M, Disertori M, Menozzi C et al (2003) The management of syncope refer- red for emergency to general hospitals with and without Syncope Unit facility.

Europace 5:293–298

9. Croci F, Brignole M, Alboni P et al (2002) The application of a standardized stra- tegy of evaluation in patients with syncope referred to three Syncope Units.

Europace 4:351–356

10. Brignole M, Menozzi C, Bartoletti A et al (2005) The best management of syncope.

Prospective systematic guideline-based evaluation of patients referred urgently to

general hospitals (in press)